Ng, Jen Min

Medicine

September 2010

Diabetes mellitus (DM) is a complex and challenging disorder for the health care provider. Delayed detection and poor glycaemic control are both associated with a significant increase in the risk of patient morbidity and mortality. With almost 1 in 25 people in the general population suffering from DM, it is crucial that this condition is managed and treated appropriately.

This thesis critically evaluates several factors that exert an influence on glycaemic control and glucose assessment in DM today. A significant proportion of the thesis discusses issues surrounding glycated haemoglobin (HbA1c) measurements in clinical practice. The thesis also examines several areas that influence glycaemic control in patients and evaluates other methods of glucose measurements including continuous glucose monitoring (CGMS), capillary glucose readings and glycated albumin. Glycaemic control in patients with diabetes can be influenced by changes in lifestyle,diet and psychological stress. The first study in this thesis summarises the effect of a flooding disaster on the glycaemic control of patients with DM.

Glycaemic control in this study was measured via longitudinal HbA1c measurements over a 24 month period. This was the first study in the UK to show that severe disruption to lifestyle, environment and psychological stress caused by a flooding disaster results in the worsening of glycaemic control in patients compared to the preceding months. The effect of the flooding was most pronounced in patients on insulin treatment (HbA1c 8.6% (8.3, 8.9) affected vs. 8.2% (8.1, 8.3) unaffected, (p = 0.002)). Glycated haemoglobin (HbA1c) concentrations have been known to be unreliable and difficult to interpret when red cell physiology is abnormal. When this occurs, glycated albumin (GA) has been suggested as a better indicator to glycaemic control. This is evaluated in the next 2 studies in a group of patients with chronic kidney disease (CKD) and DM who received intravenous iron and erythropoietin stimulating agent (ESA) therapy. Both these drugs resulted in a significant fall in HbA1c levels (0.5% in iron, p